If you want to pay me like a French doctor, also give me the French cost of medical school and the French medical malpractice system.
Kevin Pho does a great job explaining how comparisons of US physician salaries with physicians in other countries is often done out of context. One great quote in this short piece is by Princeton economist Uwe Reinhardt, on how physician salaries factor into US healthcare spending:
Cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.
This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.
This is definitely worth the 5 minutes it will take you to read.
Healthcare is big business. We are reminded of this constantly by the ever-increasing percentage of GDP that it consumes. We are currently somewhere near 18%. But healthcare has a complex relationship with our economy, one that researchers much smarter than I have yet to fully elucidate. Some question if the rise in healthcare spending is a burden on the U.S. economy, or a byproduct of it. To simplify, it is a chicken or the egg scenario without an answer of what definitively came first.
In this climate of blame, a recent study has shifted the question. Does healthcare contribute to our economy? According to a recent report by IMS healthcare and the AMA, physicians contribute 1.6 trillion dollars to the U.S. economy. This figure was derived from analyzing jobs created per physician, generated wages, and tax revenues.
This is an interesting finding, especially with the debate about physician income. As a country we value coaches and athletes to the point that we pay them exorbitant amounts of money. I recall basketball coach Jim Calhoun stating that his salary of over a million dollars was justified because of the amount of money he made for the school. Should physicians make the same arguments because of what they contribute to the economy? This is obviously tongue in cheek, but raises an interesting point -- in lean times what should we value?
But I digress.
There are concerns as to the legitimacy of the numbers. Obviously the AMA has a conflict of interest. It is also unknown how accurate the AMA master file is, which is where this information was derived from. Nonetheless, I think there is agreement that healthcare (whether we speak of physicians or the healthcare system) is a significant contributor to our economy. This reminder changes the tone of the debate on healthcare expenditures. To cut back on them means to take money out of the economy.
Personally I am a bit weary of the implications of this report. It has taken decades to bring the discussion of healthcare reform to the forefront of American politics and make it an issue citizens readily take up. It we pre-maturely promote the idea that more healthcare helps the economy I believe we will slow down the effort for reform.
I think economic conversations miss the point of healthcare: the patient. There is little evidence to support the fact that more healthcare helps patients. In fact, there are data supporting quite the opposite. However, this is a complex issue and I hesitate to make overarching claims.
Healthcare should be driven by outcomes before money. No one bats an eye at spending money on national defense and foreign wars. Why do we not feel the same about protecting our health? I would venture to guess that a healthier population contributes to a strong economy. And maybe, if we focus on health, the costs will take care of themselves.
I am someone who is very much in favor of transparency in medicine. In fact I recently pitched the idea of increasing hospital transparency to a state representative. (I highly recommend this book about that very topic.) However, the way that CMS released the Medicare data was ignorant and potentially damaging to physicians.
One of the biggest issues for healthcare right now, especially physicians, is its public image. For years doctors have been pegged as greedy, rich, and negligent. Our own president has not-so-subtly hinted at physician greed as a driver of healthcare costs. While there are few broke doctors, I believe the public's belief about a doctor's earnings is ill-informed.
Below is a slide from the MedScape Physician Compensation Report
Those do look like rather large salaries. But, like the CMS data, this is out of context. For example, we have no information about hours worked, debt load, etc. A survey of over 3,000 doctors suggest that 50% work 9-11 hours per day. Almost 20% of respondents work 12 hours or more per day.
Then there is debt accrued during medical school and residency, an expense not included in salary figures. Physicians actually start out in the negative, by hundreds of thousands of dollars. Dr. Benjamin Brown has crafted a great synopsis of this issue with a nifty graphic to explain. He isn't the only one to cite this fallacy of medicine being a financially advantageous investment. CBS News reported on it as well.
The public's view of physician earnings is not improved by the recent CMS data release. CMS has opted to release Medicare payment data with no interpretation. This means that patients are going to see raw numbers without the context of what they mean. This is problematic for many reasons. First, there will be inherent differences between private and group practices. The latter often share single billing accounts so that one individual will bill for all procedures with his or her billing code. The money is then divided up amongst all providers in the practice. This data also does not adequately represent the patient population serviced, how much of the payment goes back into overhead, etc. You can imagine that a hospice and palliative care doctor will have many more Medicare payments than an surgeon who does elective procedures. To read more about this check this New York Times Article.
Somehow the government has turned healthcare reform into patients vs doctors, and no one is winning. I am not sure if this is premeditated, but as physicians get dragged through the mud it becomes harder and harder to do their job. For example, my father has become convinced that many of the recommended tests and medications prescribed by his doctor are money making schemes, even though they are actually based in very sound medical evidence (in fact, the preventative care is now free under the ACA).
Meaningful healthcare reform requires us all to work as a team: patients, physicians, and the regulatory bodies. Pitting one against another undermines our goals of delivering safe, effective care at a reasonable price. Hopefully the government catches on to this notion in the days ahead.
You can find the New York Times's How Much Does Medicare Pay Your Doctor App here.
"Build a better mousetrap and we will use it. DVDs came out and they were better than VHS tapes. Overnight the whole world invested in new electronics, we bought DVDs and we threw out our VHS tapes. There was no need for $19B in incentives because DVDs were simply a better product. Flat screen televisions came out and we stopped buying cathode ray tube televisions. Why? Because they were a better product. Laws mandating the use of DVDs and flat screen TVs, bonuses for using them and punishments for failing to do so, were not needed. The market chose the better products."
I wrote about this topic several weeks back. This Atlantic article compiles input from several physicians and their thoughts on electronic health records, with some extremely valid points being made - it is definitely worth a read. Also, check out the article these statements in response to.
The legal industry's obsession with performance metrics has contributed to its dramatic collapse. Could the same happen with physicians and hospitals?
This is something I have been meaning to write about, but this Atlantic article does a pretty amazing job at laying out the problem. I strongly encourage all of my subscribers to read and share.
The Broken Promise of the Electronic Health Record
Before starting medical school, I went through the process of purchasing a new computer. There was a plethora of options, each with sales representatives primed for the opportunity to explain why their product was superior. I needed something that would last, would be compatible with all the programs I would use, would be reliable, affordable, etc. The list of “wants” was as long as my arm, but ultimately I wanted something that would work. With the breakneck speed that technology advances, it can be daunting trying to forecast what will be relevant 5 to 10 years down the road.
The experience of buying a new computer helps me to identify with all of the physicians currently going through the Electronic Health Record (EHR) shuffle. An estimated 300 plus electronic health record systems are on the market today. Doctors, hospitals and group practices are facing the same struggles I faced: what is the best system, the most economical choice, and the one that will remain relevant 10, 20, or 30 years down the road?
With so many choices it has been hard for smaller hospitals and practices to find a system that fits their needs. Furthermore, with the purchase of an EHR system come other necessary expenditures – new computers that are compatible, IT staff, training, etc. Many smaller practices find it hard to deal with the overhead associated with the upgrade.
Electronic health records hold great promise for patient care. Researchers at the University of Missouri, in partnership with Cerner, have created statistical algorithms that use patient data for early detection of disorders like sepsis. In many cases, the computer system has predicted the deterioration of patients prior to clinical manifestations. This gives healthcare workers lead-time to get in front of devastating infections. Early treatment in sepsis improves outcomes, and technology like this has the ability to dramatically improve patient survival rates.
EHRs also allow physicians to track longitudinal patient data, helping them to understand disease processes on an individual level. Many of the health metrics stored in EHRs will be the basis for outcomes-based payment, something the government and many insurers are moving toward. There is significant potential to improve treatment and quality of life for a large number of patients.
However, the rollout of EHRs has been a bit of a disaster. Despite being around for decades and the numerous incentives the Obama administration has tied to their use, the National Center for Health Statistics reports that only 78% of office-based physicians use an EHR system [1]. Perhaps worse is a survey by the American College of Physicians, which reported in March that of 4,279 responding physicians, 34% were “very dissatisfied” by their EHR system, and 32% reported their productivity had decreased since implementation [2]. These findings are a bit generous, many studies report even greater dissatisfaction.
There are few physicians who would argue that EHRs are a bad idea. But based on a recent RAND corporation study on physician job satisfaction, EHRs contribute to numerous problems in physician workflow. Findings conclude that many EHR systems require time-consuming data entry, in numerous and sometimes redundant fields, via navigation through complicated and illogical menu systems. To ease the burden of data entry, some EHR systems and physicians have taken to using templates; however, physicians note there is danger in attempting to standardize each patient record, and copy/pasting allows errors to propagate throughout a patient’s record [3, 4].
Additionally, there is concern that EHR complexity is eating into patient-physician interactions. A study on ER physicians found that the average physician accrued a total of 4,000 mouse clicks over a 10-hour shift and spent more time entering data than any other single activity – including seeing patients [5]. Some physicians have elected to try and enter records as they communicate with patients, but studies have shown that this can be a detractor from the interaction. The computer provides a literal and psychological barrier to good communication.
The EHR fiasco is only going to get worse as use of ICD-10, a new coding system, becomes mandatory in October. ICD, which stands for International Classification of Diseases, is a system of codes that standardizes diagnoses and procedures across the world. This update has the medical world in a frenzy and has already been delayed a year. It will dramatically increase the complexity of EHR operation and require significant updates, compounding the problems already experienced by most physicians. To illustrate the reasons for consternation, ICD-10 will increase the number of diagnosis codes from 14,000 to 68,000 and the number of procedure codes from 4,000 to 87,000.
So what can be done to improve EHR usability? For over 10 years multiple organizations and journals have published numerous reports about what would make EHR systems better. A Health Affairs article in 2004 noted that EHRs could be improved if they were easier to use, had better support, and could exchange data between multiple systems [6]. Why is it that physicians have the same complaints a decade later?
There are pockets of improvement, but overall progress has been slower than most healthcare workers would like. Groups like the University of Missouri and Cerner have been working alongside each other to ensure physicians directly influence EHR design, but not all vendors offer this kind of opportunity. There are also numerous other hurdles that still exist. Communication across health record platforms needs to be implemented if we are to move into the era of integrative, multidisciplinary care. EHR systems should have a more standardized layout so that meaningful health record training can occur earlier in medical training (i.e. in medical school). And clinicians should have a direct hand in the design of EHR systems, and their user interface, to maximize workflow efficiency.
We have gotten a taste of what EHRs can do and the possibilities their use holds. But without improving the physician experience we may be further away from meaningful use than healthcare workers, and the government, would like. It is time for Electronic Health Records to undergo significant improvement so that healthcare workers can get back to their most important role – taking care of patients.
Written by Nathanial S Nolan
Citations
[1] Hsiao CJ, & Hing E. (2014, January). NCHS Data Brief - Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. Centers for Disease Control and Prevention. Retrieved January 26, 2014, from http://www.cdc.gov/nchs/data/databriefs/db143.pdf
[2] Survey of Clinicians: User satisfaction with electronic health records has decreased since 2010. (2013, March 5). American College of Physicians. Retrieved January 26, 2014, from http://www.acponline.org/pressroom/ehrs_survey.htm
[3] Friedberg MW, Chen PG, Van Busum KR, Aunon FM, Pham C, & Caloyeras JP. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. RAND Corporation. 2013. ISBN 978-0-8330-8220-6
[4] Quality of Patient Care Drives Physician Satisfaction; Doctors Have Concerns About Electronic Health Records, Study Finds. (2013, October 9). American Medical Association. Retrieved January 26, 2014, from http://www.ama-assn.org/ama/pub/news/news/2013/2013-10-09-rand-study-physician-satisfaction.page
[5] Hill RG, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31(11):1591-4.
[6] Miller RH, Sim I. Physicians' Use Of Electronic Medical Records: Barriers And Solutions. Health Affairs. 2004;23(2):116-126.
Kumar S, Aldrich K. Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study. Health Informatics J. 2010;16(4):306-18
Ruotsalainen P. A cross-platform model for secure Electronic Health Record communication. Int J Med Inform. 2004;73(3):291-5.
A decade ago, Missouri medicine was in crisis mode after the revocation of the state malpractice cap. In the mid-1980s, Missouri set laws that limited noneconomic damages in medical malpractice cases at $350,000 — a limit that was indexed based on inflation and thus would increase annually. In 2002, the Missouri Eastern District Court of Appeals issued a decision in Scott v. SSM Health Care that effectively nullified the cap. As part of the decision, the court set a precedent that each "occurrence" of negligence could accrue noneconomic damages, which at that time was more than $550,000. In practical terms, that meant for each person on the care team, for each day the diagnosis was missed and for each diagnostic study based on an erroneous diagnosis, the patient could receive noneconomic damages. Though each instance claimed couldn't exceed the cap, the total "occurrences" had no limit. In essence, there was no longer a cap.
In subsequent years, the number of lawsuits and the cost of malpractice insurance dramatically increased. According to the National Practitioner Data Bank, which records physician claims, the number of claims against physicians rose by 37 percent between 2000 and 2004. In 2003, the number of frivolous claims, those that resulted in no payment, rose by 73 percent. Though no payouts occurred, the average cost of defending each claim totaled more than $11,000. For the lawsuits ended with indemnity, the average sum increased by 50 percent between 2001 and 2004.
This resulted in a dramatic increase in malpractice premiums. According to surveys by the Missouri State Medical Association (MSMA), the average increase in malpractice premiums per physician was 61.2 percent between 2002 and 2004. In a survey of every neurosurgeon in Missouri, the average increase was 116 percent between 2001 and 2003. The insurance companies were still losing money, however, and many opted to leave the state. Between 2001 and the end of 2002, a total of 24 malpractice insurance carriers stopped serving Missouri, leaving just eight.
Physicians also began to leave the state. At the end of 2002, more than 200 physicians had left or retired early. By 2004, according to an MSMA survey, 29 percent of Missouri physicians were considering leaving the state and 17 percent were considering early retirement.
Then, in 2005, Gov. Matt Blunt signed into law a bill restoring caps on noneconomic damages. These were again set at the $350,000 limit. Between 2005 and 2012, the number of claims dropped by almost 50 percent, the indemnity of paid claims dropped by 20 percent and premium decreases amounted to $27 million across the state.
Now the crisis is happening again. On July 31, 2012, the Missouri Supreme Court overturned the 2005 law, declaring caps infringe "on the jury's constitutionally protected purpose of determining the amount of damages sustained by an injured party." The 4-3 decision was propelled forward with a vote from a specially appointed judge who filled in for Judge Zel Fischer.
The case in question is Watts v. Cox Medical Center, which alleged Naython Watts suffered brain damage attributable to negligent prenatal care. Before the Supreme Court decision, the plaintiff was awarded $3.721 million in damages. This was substantially less than the $8.5 million requested by the plaintiff and the $4.821 million that would have been awarded by the jury without the cap. Watts' attorney, whose fees were 40 percent of the award, challenged the economic cap, taking the case to the Missouri Supreme Court.
The Missouri State Medical Association, Missouri Chamber of Commerce and many state lawmakers have come out in opposition to this decision. This past legislative season, a proposal to restore caps on noneconomic damages could not pass in the Missouri legislature because of a Senate filibuster. The MSMA continues to lobby in the state legislature in anticipation that progress will be in made in 2014.
Medicine across the country is at a crossroads. In a time of tumultuous change, leaders are searching for ways to both improve care and lower costs. Trial lawyers argue caps protect bad physicians and don't incentivize safe care. Years of data from across the U.S., however, demonstrate that, when caps are removed, the number of cases filed increases but the number of successful cases decreases. This doesn't help patients; it only increases administrative costs of defending malpractice cases — costs that invariably trickle down to patients. The cost of defending frivolous lawsuits increases malpractice premiums across all medical specialties. This is analogous to prophylactically increasing an individual's car insurance expecting it will make him a better driver.
There are many other and better ways to incentivize safe care, several of which are part of the Affordable Care Act. The last repeal of a cap on noneconomic damages saw an exodus of physicians from Missouri attributable to the increases in practicing costs. With the looming shortage of primary care physicians — and health care providers in general — Missouri can't afford to have this happen again. If we don't take this opportunity to learn from the past, we will continue to repeat it, leaving doctor-less patients saddled with the consequences.
Written by Nathanial S Nolan. Originally Published in the Columbia Tribune.
Is Shortening Medical Education the Answer to the Doctor Shortage?
The predicted shortfall of doctors in the coming decade has become a prominent feature in the news, especially with the opening of the Insurance Exchange and enactment of the Affordable Care Act’s final pieces. This has prompted the most forward-thinking minds in medicine to propose solutions to bridge this gap. Some think that giving more responsibility to nurses, nurse practitioners and physician’s assistants is the answer. Others believe that TeleHealth, getting healthcare over an Internet or video connection, will help smaller communities in need of physicians. Amidst this plethora of proposed fixes, one idea, which was recently debated in the New England Journal of Medicine (NEJM), seems to be gaining traction: limiting medical training to 3 years.
Currently, medical students are required to get an undergraduate degree before pursuing medical school. For most this requires 4 years of school. Medical school requires another 4 years, and to be a fully licensed practicing physician one must finish an accredited residency, the shortest of which is 3 years. That is roughly 11 years for most primary care providers and, according to some, far too long. This is why several schools, including New York University School of Medicine, have created a 3-year medical school curriculum.
This past September NEJM published two articles, one for and one against 3-year M.D. programs. Certainly a 3-year program would shorten the time it took to get through medical school, and would also save students a year of tuition [1, 2], which at some institutions is upwards of $50,000. However, this does not address the underlying issue, which is the dramatic increase in medical school debt over the past two decades. Currently the cost of medical education is rising at twice the rate of inflation [3, 4]. There are expectations that reducing loan debt will also spur more students to enter primary care, but studies have demonstrated that money is not the only factor in choosing a medical specialty, and loan repayment programs, which offer loan reduction to students who practice primary care, have had mixed results [5].
There also seems to be a lack of consensus about the readiness of medical students for clinical duty. Though proponents of shorter medical school programs uphold that students can meet training requirements with less education, a survey of residency program directors suggest otherwise. A study published in Academic Medicine in 2009 actually suggested that the fourth year of medical school be revamped to include more training for medical students before they enter residency [6]. This recommendation that students require more training is contrary to the recommendation that we cut the fourth year out altogether.
Finally, and perhaps the most damning feature of this plan is that it has been tried before. In the 1970s many medical schools offered a 3-year curriculum in an attempt to boost the number of physicians because of a predicted shortage. The University of Arizona reported that their attempt at a 3-year program was “an unsatisfactory experience” for educators and students alike. They returned to the 4-year program because the 3-year program led to “excessive intensity of classroom work” and “inadequate time to teach important basic science material [7].” More than 50% of surveyed institutions with 3-year programs reported faculty dissatisfaction and worry over the amount of material cut out of the curriculum [8, 9]. Students also seemed to have misgivings about their education. A quarter of them opted to extend their education by a year or more [10]. With the explosion of medical knowledge since the 1970s, the proposal of a 3-year program seems doomed for failure.
Medical education is an important issue that will invariably be a part of improving our nation’s healthcare. Reform is needed, but it needs to be evidence-based and well thought out. There may be a role for shortening medical school for special populations of students, such as those with advanced science degrees. Students wishing to practice primary care may also provide an opportunity for shortening medical school, especially if their fourth year of medical school becomes an integrated year of practice and training – allowing medical school and residency to overlap. However, a blanket policy of rushing students out the door as a way to fill the physician shortage does not seem wise or sustainable. Only after the outcomes of these current programs are published will we know if this time around the 3-year M.D. will be the fix for our doctor shortage.
Written by Nathanial S Nolan
Citations
1. Abramson SB, Jacob D, Rosenfeld M, et al. A 3-year M.D. – accelerating careers, diminishing debt. N Engl J Med. 2013;369(12):1085-7.
2. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA. 2012;307(11):1143-4.
3. Adashi EY, Gruppuso PA. Commentary: the unsustainable cost of undergraduate medical education: an overlooked element of U.S. health care reform. Acad Med. 2010;85(5):763-5.
4. Youngclaus, J., & Fresne, J. A. (2013, February). Physician Education Debt and the Cost to Attend Medical School 2012 Update. Association of American Medical Colleges.
5. Steinbrook R. Easing the shortage in adult primary care--is it all about money?. N Engl J Med. 2009;360(26):2696-9.
6. Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med 2009;84:823-9.
7. Kettel LJ, Dinham SM, Drach GW, Barbee RA. Arizona's three-year medical curriculum: a postmortem. J Med Educ. 1979;54(3):210-6.
8. Page RC, Boulger JG. An assessment of the three-year medical curriculum. J Med Educ 1976;51:125-6.
9. Berman BU. Three-year programs in medical and dental schools: an appraisal. Public Health Rep. 1979;94(1):85-7.
10. Goldfarb S, Morrison G. The 3-year medical school--change or shortchange?. N Engl J Med. 2013;369(12):1087-9.
“The hardest conviction to get in the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.” – Sir William Osler
When Osler started the first residency at Johns Hopkins, it was customary for resident doctors to live in the hospital. In fact, this is where the term “resident” came from. These young physicians were also called the “house staff,” a term coined because the hospital was their house, so-to-speak. But gone are the days of Osler, which have given way to an era where students speak of medicine as a job rather than a profession. Hour restrictions have been implemented so that patients are safer and students have a more reasonable lifestyle. Only this hasn’t panned out very well. Once our residents quit being “residents of the hospital,” the threat to patients actually increased and student morale decreased.
Due to mounting pressure over the last decade, the ACGME has been placing tighter restrictions on the amount of hours that medical residents are allowed to work [1]. At the turn of the century, reports from the National Institutes of Health highlighted the staggering number of deaths attributed to medical errors. Specifically, the report To Err is Human suggested that up to 98,000 Americans die each year due to preventable medical errors [2]. This prompted a reform in resident work hours in 2003, and a second reform in 2011. Current work restrictions, based on 2008 IOM recommendations, are 80 hours per week averaged over 4 weeks. First year residents are limited to shifts of no more than 16 hours, with all other residents able to work 24 hours in a row.
Initial reports from residents, following the 2003 implementation of work hour restrictions, suggested an improved quality of life. However, they also suggested that their education was suffering, and that a decreased continuity with patients may actually increase errors [3]. The 2011 restrictions apparently made things worse rather than better. Residents reported lower survey scores of well-being and higher survey scores for stress. A study of pediatric residents demonstrated that they experienced severe work compression. They had the same patient load, but fewer hours to see patients [3]. This was echoed in a study on medical interns [5]. There was also a notable impact on attending physicians, giving them fewer hours in which to teach residents and increasing their own patient load [6].
There is also worry that surgery residents may not be gaining enough procedural experience. To become a proficient surgeon, students need to repeat procedures over and over. This allows them to see differences in anatomy and handle a wide array of surgical complications so that, when they do not have a supervising physician, they can adequately lead a team. However, according to multiple studies, the reduction in resident work hours has led to less time for students to be in surgery [7, 8]. Surgical interns report less time with patients, higher rates of burnout and frequent thoughts of quitting surgery [9].
Several initial studies of the 2003 changes demonstrated that the restrictions allowed for minor improvements in patient outcomes. While no significant benefit or worsening was found in one study [10], some small benefits were found in others [11, 12]. For example, one medical center saw a reduction in usage of its intensive care unit and fewer interventions by pharmacists over medication errors. However, the decrease in interventions was only 2 per 100, and they saw no difference in readmission rates, adverse drug-drug interactions, length of hospital stay or other outcome measurements [11]. Another study found a reduction in mortality rate of 0.25%, which is not much, but is statistically significant [12]. More importantly, for people in that small percentage, any improvement matters. Even if residents felt more stress, the argument could be made that work hour restrictions are necessary if it improves patient care.
Further studies of the 2011 restrictions offered a bleaker picture. A troubling outcome from these reforms was published just this year in the Journal of the American Medical Association. A longitudinal study that compared data from prior to the 2011 changes showed that interns reported more medical errors after the restriction [13]. How could this be? How could regulations designed to help residents and patients potentially harm both?
This problem results from a combination of factors. We currently have a shortage of resident physicians, while we have an increase in patients needing care. This equates to more work per physician – including residents. Many of the community teaching hospitals rely on a resident work force to take care of their patient populations, particularly Medicare and Medicaid patients. While adding more work to our junior physicians’ plates, we have also reduced the hours they have to do that work. They are studying less, spending less time in education events [14] and lying on their time sheets [15] just to be able to satisfy their patient care requirements.
There is also a reduction in the amount of time actually spent with patients. A 2011 study reported that as duty hour restrictions have been put in place, students have spent less time with patients [16]. When you give someone a set number of hours, there is only so many ways they can divide it. Concerns have also been voiced over the increased number of patient hand-offs that occur when shifts are shorter. Anytime a patient is handed-off to a new provider, there is a chance of misinformation. Multiply this by the fact that each shift change involves the transfer of many patients. An intern, rushed for time, may hand-off multiple patients forgetting to tell the incoming team that Mrs. Baker in room 301 just got her meds but he/she hadn’t had time to chart it. This could lead to a disastrous outcome, and may be the reason for the increased rate of errors.
The answer to this problem is not an easy one. Do we limit the amount of patients that residents can see? This would surely reduce the amount of work compression they feel. It would also reduce the amount of learning. Medical education is built upon experience. Only after doctors have seen a thousand colds can they look at a patient and think, “this isn’t a typical cold.” Diagnostics is an art that can’t be mastered by reading a book. To again borrow from Osler, “to study the phenomena of disease without books is to sail an uncharted sea, while to study disease without patients is not to go to sea at all.”
The solution may lie with transparency. The more that we publish our mistakes, the more we are able to learn from them. There are also direct repercussions for the quality of care you provide – hospitals are incentivized to reduce mistakes if their error rate is published regularly. This would allow residencies to police their own residents rather than assuming one rule will work for every training center. Hospitals have completely different shift schedules, overnight support, populations, numbers of residents, etc. The shift schedules and work limits that work for one hospital may be extremely detrimental to another.
Medical education should be evidenced-based, like the treatments prescribed to patients. If studies were published showing that a drug did not work, it would not be prescribed (ideally). A decade after we started this regulatory experiment, we are seeing that the prescription isn’t working. It’s time to lose the national regulations and let hospitals regulate themselves. As a replacement, academic hospitals should be forced to publicly release their error rates. This serves as a monumental teaching opportunity and allows for rapid feedback and adjustments. The fine-tuning of hospital-regulated shift length and work restrictions would allow for multiple experiments to happen simultaneously. As one institution finds success, other institutions are likely to adopt their method as they also vie to reduce their own error rates.
We may not need students to live at the hospital in order to make them good doctors. But forcing them to stay away from it seems worse. Osler thought medical education was but a preparation for life. I can think of no better preparation than demonstrating to residents the importance of patient safety.
Written by Nathanial S Nolan
Citations
1. ACGME Duty Hours. Accreditation Council for Graduate Medical Education. Retrieved September 14, 2013, from http://www.acgme.org/acgmeweb/tabid/271/GraduateMedicalEducation/DutyHours.aspx
2. Kohn L T, Corrigan J M, Donaldson MS (Institute of Medicine) To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.
3. Myers JS, Bellini LM, Morris JB, et al. Internal medicine and general surgery residents' attitudes about the ACGME duty hours regulations: a multicenter study. Acad Med. 2006;81(12):1052-8.
4. Auger KA, Landrigan CP, Gonzalez del rey JA, Sieplinga KR, Sucharew HJ, Simmons JM. Better rested, but more stressed? Evidence of the effects of resident work hour restrictions. Acad Pediatr. 2012;12(4):335-43.
5. Arora VM, Georgitis E, Siddique J, et al. Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities. JAMA. 2008;300(10):1146-53.
6. Typpo KV, Tcharmtchi MH, Thomas EJ, Kelly PA, Castillo LD, Singh H. Impact of resident duty hour limits on safety in the intensive care unit: a national survey of pediatric and neonatal intensivists. Pediatr Crit Care Med. 2012;13(5):578-82.
7. Connors RC, Doty JR, Bull DA, May HT, Fullerton DA, Robbins RC. Effect of work-hour restriction on operative experience in cardiothoracic surgical residency training. J Thorac Cardiovasc Surg. 2009;137(3):710-3.
8. Damadi A, Davis AT, Saxe A, Apelgren K. ACGME duty-hour restrictions decrease resident operative volume: a 5-year comparison at an ACGME-accredited university general surgery residency. J Surg Educ. 2007;64(5):256-9.
9. Antiel RM, Reed DA, Van arendonk KJ, et al. Effects of duty hour restrictions on core competencies, education, quality of life, and burnout among general surgery interns. JAMA Surg. 2013;148(5):448-55.
10. Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform. JAMA. 2007;298(9):975-83.
11. Horwitz LI. Changes in Outcomes for Internal Medicine Inpatients after Work-Hour Regulations. Ann Intern Med. 2007;147(2):97-.
12. Shetty KD. Changes in Hospital Mortality Associated with Residency Work-Hour Regulations. Ann Intern Med. 2007;147(2):73-.
13. Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study. JAMA Intern Med. 2013;173(8):657-62.
14. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: a randomized trial. JAMA Intern Med. 2013;173(8):649-55.
15. Szymczak JE, Brooks JV, Volpp KG, Bosk CL. To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?. Milbank Q. 2010;88(3):350-81.
16. Alromaihi D, Godfrey A, Dimoski T, Gunnels P, Scher E, Baker-genaw K. Internal medicine residents' time study: paperwork versus patient care. J Grad Med Educ. 2011;3(4):550-3.
Since 1983 medical students across the U.S. have used the U.S. News & World Report as a way to compare schools and decide where to apply. Using their own collection of data, the U.S. News & World Report scores medical schools on various factors, such as number of applicants versus matriculants (a measure of exclusivity) and reputation amongst other medical schools. In the end they produce a yearly report of schools based on ranking in research and primary care focus [1]. But according to a new article in the Journal of Academic Medicine, these rankings may not be very accurate, skewing the perceptions of students who may rely on them [2].
This isn’t the first time critiques of the U.S. News & World Report have been brought forth. In 2001, Academic Medicine published another paper blasting the measures used to assess medical schools. The problem, as they state, is that “uncritical consumers believe these data provide the only available objective, unbiased way to assess and compare U.S. medical schools [3].” For example the ranking system uses matriculant undergraduate statistics, like MCAT and GPA [4]. These statistics are not at all indicative of the education a school provides. How can you use the status of students prior to attendance as a way to gauge a school? Furthermore this discourages schools from taking students who might be underwhelming on paper, but overall may add diversity to the program [5].
Approximately 40% of the ranking system employed by the U.S. News & World Report relies on survey data from school administrators and residency directors [2]. However, less than 50% of medical school deans and less than 20% of residency directors actually reply to these surveys [4]. This was also brought up in 2001 by McGaghie and Thompson, who stated that such a low response rate would not hold up against any sort of scientific standards [3]. When ranking is based on reputations, multiple errors arise. First, the schools with good reputations – the Harvards and Washington Universities – always get ranked high, no matter their actual effectiveness or outcomes. Second, it can take only one misstep to cause a bad reputation. Highly publicized hospital errors may reflect poorly on the school attached to the hospital even though the error did not involve the students or any school faculty.
Further errors occur when ranking medical programs on primary care. For ranking, the U.S. News & World Report uses the percentage of graduates, from a given school, who enter primary care specialties, namely pediatrics, internal medicine and family medicine. However, many students who enter pediatrics or internal medicine do so only to go on and specialize [2]. Furthermore, they do not account for students who serve in underserved areas. Mullan and colleagues have proposed ranking schools on how well they fulfill their social mission – providing an adequate primary care physician supply to underserved areas [6].
The study in Academic Medicine determined that when compared by the most objective measures, schools tended to cluster around the center. The schools that stood out did so based upon reputation scores (i.e. the subjective surveys, with an extremely low return rate, listed above). The top 7 schools were virtually indistinguishable – showing statistical difference where none is found. This is, in the author’s words, “distinctions without differences [3].” Basically, with few exceptions, the education at most U.S. medical schools is pretty comparable.
So how should we rate schools? McGaghie and Thompson argue that factors like inclusion of minorities, assessments of clinical skills and service to the underserved constitute more accurate measures of a school’s performance [3]. Others, particularly medical students, have argued that USMLE scores and resident placement are direct reflections of a school’s ability to educate. However this is also fraught with error. A single score on a single test does not accurately predict abilities. Students may be great at paper tests but terrible with patients. Match lists are also poor predictors as many students opt to go to smaller residencies in rural areas, which might reflect poorly if prestige of residency was a factor.
In my opinion we are trying to measure something that is immeasurable. How can you compare the varied education systems across schools? Theoretically the US Medical License Exams ensure that students are qualified to enter the physician workforce. And the LCME accredits schools, maintaining the integrity of education in the U.S. Is ranking schools necessary? Doesn’t it place competition where none should exist? Getting into medical school is hard enough without adding consternation over going to the “best” school. In my opinion, students should go where they feel most comfortable. They should choose a school that matches their interests, budget and future practicing aspirations. I believe good doctors are born out of hard work and compassion, not because they went to a number 1 school.
What do you think? Should we rank schools? And if so, how?
Written by Nathanial S Nolan
Citations
1. Best Medical Schools. In U.S. News & World Report. Retrieved September 5, 2013, from http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-medical-schools
2. Tancredi DJ, Bertakis KD, Jerant A. Short-Term Stability and Spread of the U.S. News & World Report Primary Care Medical School Rankings. Acad Med. 2013;88(8):1107-1115.
3. McGaghieWC, Thompson JA. America’s Best Medical Schools: A Critique of the U.S. News & World Report Rankings. Acad Med. 2001:76(10):985-992
4. Jerant, A. (2013, July 8). Are the 'U.S. News' medical school rankings for primary care education relevant?. In U.C. Davis Health System. Retrieved September 5, 2013, from http://www.ucdmc.ucdavis.edu/publish/news/newsroom/7993
5. Mogul, F. (2011, October 28). Medical Schools Say Magazine's Ratings Get An Incomplete. In NPR. Shots. Retrieved September 6, 2013, from http://www.npr.org/blogs/health/2011/10/28/141797946/medical-schools-say-magazines-ratings-get-an-incomplete
6. Mullan F. The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med. 2010;152(12):804-811.
Raise your hand if you know someone who has been affected by cardiovascular disease. The vast majority of people reading this will be in that category. Heart disease is the leading cause of death in the U.S., accounting for 600,000 deaths a year. To put that into perspective 1 of every 4 deaths will be associated with heart disease [1]. This is a serious disease burden to the U.S., to put it mildly.
In 1948 the National Heart Institute (now the National Heart, Lung and Blood Institute) set about studying the overwhelming epidemic of cardiovascular disease that was occurring in the U.S. [4]. Since then it has been the catalyst for some of the biggest discoveries in health. Just a few examples include: the relation of HDL and cardiovascular disease, risk factors associated with atrial fibrillation, and high blood pressure’s relation to stroke. Many of the things we take for granted as common medical knowledge now, that cigarette smoking is linked to heart disease for example, were first elucidated in the Framingham cohort (that previous discovery occurred around 1960). More recently the study has been heavily involved in researching risks associated to Alzheimer’s disease, another disease with a high burden on the U.S. healthcare system [5].
The overwhelming cuts to science research in an effort to reduce the deficit represent a dangerous situation in the U.S. An illustration of this is the National Institute on Aging (NIA), which in 2010 funded only 8% of grant proposals [6]. How can we expect to improve care and outcomes for an aging population if no one will fund the research? This trend is only getting worse. In 2013 the National Institutes of Health (NIH) has been working to cut $1.55 billion from its budget. This amounts to 700 less grants being funded, which will hinder biomedical research. These cuts will also directly destroy science jobs that have historically been supported by research funding [7, 8].
Less that 1% of the federal budget actually goes into basic research. Slashing this budget does little to improve the national debt, however it does threaten to damage the future of medicine, science and our economy [9]. The American Statistical Association has proposed that investing more into research would help bring the economy back to the levels of growth we saw in the 1990s [10]. The return we see on government funded scientific research is anywhere between 30-100% or more [11]. Take the case of the human genome project, for an investment of $3.6 billion the U.S. received a return of approximately $1 trillion. That’s $178 for every dollar the U.S. spent [11, 12].
The sequestration of science funding is also forcing researchers out of the U.S. According to a survey by the American Society for Biochemistry and Molecular Biology, of more than 3700 respondents, 1 in 5 is considering leaving the country to pursue research elsewhere [13]. This is a staggering number – and it is not hard to predict what a loss of this proportion will do to research and development. If the U.S. continues on this trajectory we may lose out on important and economy-boosting innovations.
There is fervor among politicians to reduce the national debt. But we must be careful that those cuts won’t hurt the future of our country. We need the Framingham study, and hundreds more like it, to continue pushing the U.S. to be a leader in healthcare and science innovation. Translation of science into the clinic can take years, and if we kink the hose now, it may be several years before the effects are felt – but they will be felt.
If you raised your hand at the beginning of this piece you have been intimately touched by scientific research. Your experience was a by-product of investment of both time and money. If we quit investing, the future may be full of individuals who won’t get that benefit.
Written by Nathanial S Nolan
For more resources check out saveresearch.org
Citations
1. Heart Disease. Facts and Statistics (2013, August 28). Centers for Disease Control and Prevention. Retrieved August 30, 2013, from http://www.cdc.gov/heartdisease/facts.htm
2. O'Riordan, M. (2013, August 29). Framingham Heart Study Funding Cut by 40%. In MedScape. Retrieved August 30, 2013
3. Winconeck, J. (2013, July 25). Framingham Heart Study Facing $4 Million in Cutes. In Boston.com. Retrieved August 30, 2013
4. History of the Framingham Heart Study (2013, August 28). In Framingham Heart Study. Retrieved August 31, 2013, from http://www.framinghamheartstudy.org/about/history.html
5. Research Milestones (2013, August 28). In Framingham Heart Study. Retrieved August 31, 2013, from http://www.framinghamheartstudy.org/about/milestones.html
6. Wadman, M. (2010, November). Funding crisis hits US ageing research. Nature, 148(468). doi:10.1038/468148a
7. Fact sheet: Impact of Sequestration on the National Institutes of Health (2013, June 3). In National Institutes of Health. Retrieved August 31, 2013
8. Stein, S. (2013, August 15). Sequestration Ushers in a Dark Age for Science in America. Huffington Post. Retrieved August 31, 2013
9. Alivisatos, P., Isaacs, E. D., & Mason, T. (2013, March 12). The Sequester is Going to Devastate U.S. Science Research for Decades. The Atlantic. Retrieved August 31, 2013
10. Reikard, G. (2011, March 1). Stimulating Economic Growth Through Technological Advance. AMSTATnews. American Statistical Association. Retrieved August 31, 2013, from http://magazine.amstat.org/blog/2011/03/01/econgrowthmar11/
11. Pool, S. & Erickson, J. (2012, December 10). The High Return on Investment for Publicly Funded Research. In Center for American Progress. Retrieved August 31, 2013, from http://www.americanprogress.org/wp-content/uploads/2012/12/InnovationResearchInvestments-1.pdf
12. Wadman, M. (2013, June 12). Economic return from Human Genome Project grows. Nature. doi:10.1038/nature.2013.13187
13. Stein, S. (2013, May 2). Sequester Impact On Medical Research Results In Cuts To Promising Projects. Huffington Post. Retrieved August 31, 2013, from http://www.huffingtonpost.com/2013/05/02/sequester-impact-medical-research_n_3203089.html
14. Unlimited Potential, Vanishing Opportunity (2013). In The American Society for Biochemistry and Molecular Biology. Retrieved August 31, 2013, from http://www.asbmb.org/uploadedFiles/Advocacy/Events/UPVO%20Report%20V2.pdf
Imagine you, like most traditional medical students, went to college for four years to earn an undergraduate degree. If you are like many students you may also have obtained a graduate degree or worked for a period of time. You then spend time and money fulfilling extracurricular activities, taking the Medical College Admission Test (MCAT), applying to schools and traveling for interviews. If you are part of the lucky minority, roughly 40% [1], you will be granted entrance to a medical school to spend four more years and tens of thousands of dollars to graduate as a physician.
Imagine you do all this, only to find you have no job.
Jobless doctors? At one point in time that would have been preposterous, but just last year over 500 U.S. M.D. graduates did not obtain a residency position [2]. This total does not include the thousands of D.O. students and international medical students who were also not matched. According to the National Resident Matching Program, the organization that matches allopathic medical students with their graduate medical training sites, over 13,000 applicants were unmatched in the initial process and participated in a supplemental program (the Supplemental Offer and Acceptance Program, a.k.a. the SOAP). In all 34,355 U.S. and international medical students were competing for 26,392 positions [3].
This seems like an interesting predicament for a country fearing an imminent physician shortage. By some estimates the U.S. will be short over 60,000 physicians in the next 2 years [4]. This is also devastating to students. Without a residency position you cannot practice medicine, and therefore cannot earn a living. That is scary news to the average medical student who graduates with over $160,000 in debt [5].
At this point you might be wondering what the problem is. Where is the hang up in the system we trust to train an adequate physician work force? There are actually several problems, all of which come down to the funding of Graduate Medical Education (GME). GME funding is directly tied to Medicare and indirectly tied to Medicaid. Anything that affects Medicare and Medicaid will invariably affect residency training positions. The most prominent example is the Balanced Budget Act of 1997 (BBA). In essence this bill stated that reimbursements to hospitals for training doctors would be frozen at 1996 levels. An increase in the number of doctors a hospital trained would bring in no extra government reimbursements [6]. Basically we can’t train any more doctors than we did in 1996 – even with an aging population and looming shortage.
Unfortunately, or fortunately depending on how you see the picture, medical schools have increased class sizes and the number of graduating doctors in an effort to stall and/or prevent a national shortage. By 2017 there will be 30% more students enrolled in medical school as compared to 2002 [7]. As you can probably see, this creates a bottleneck, one that became evident this year. It will only get worse as students who did not match this year apply again next year, only to find themselves competing with an increasing number of graduating applicants.
If things continue, further cuts in residency positions will occur. The 2014 fiscal budget proposes $11 billion dollars in Medicare cuts over the next 10 years. This equates to a decrease in GME funding from Medicare by roughly 10% a year [8]. We cannot afford to lose 10% of our residency positions.
Residency positions are important to the health of our nation, and the health of our healthcare system. They represent a large portion of care for the elderly, disabled, and indigent. Residents also reflect the future of medicine. As our nation ages and faces a dramatic increase in the insured population we cannot afford to face a shortage. As a student of Public Health, I fear the repercussions for the U.S. healthcare system. As a medical student I fear the repercussions for myself. I want to treat patients. I want to work in a community. I want to provide charity care.
Lately though, I just want a job.
Written by Nathanial S Nolan
Citations:
1. Table 1: U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2011 (2011, November 2). In Association of American Medical Colleges. Retrieved August 20, 2013, from https://www.aamc.org/download/161128/data/table1.pdf
2. Herbert, C. (2013, April 3). Final NRMP® Residency Match 2013 Results Show 99.4 Percent of Positions Filled. In National Resident Matching Program. Retrieved August 20, 2013, from http://www.nrmp.org/pressreleasepostmatch2013.pdf
3. Results and Data - 2013 Main Residency Match (2013, April). In National Resident Matching Program. Retrieved August 20, 2013, from http://www.nrmp.org/data/resultsanddata2013.pdf
4. Rye, B. (2012, February 28). Assessing the Impact of Potential Cuts in Medicare Doctor-Training Subsidies. In Bloomberg Government. Retrieved August 21, 2013, from http://about.bgov.com/bgov/files/2012/03/ryestudy.pdf
5. Medical Student Education: Debt Costs and Loan Repayment Fact Card (n.d.). In Association of American Medical Colleges. Retrieved August 21, 2013, from https://www.aamc.org/download/152968/data
6. Medicare Resident Limits (n.d.). In Association of American Medical Colleges. Retrieved August 21, 2013, from https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html
7. Kirch, D. G. (2013, June). A Word From the President: Taking a Lesson from the 2013 Match. In Association of American Medical Colleges. Retrieved August 21, 2013, from https://www.aamc.org/newsroom/reporter/june2013/346238/word.html
8. GME Funding Remains in Critical Condition (2013). In American Medical Association. Retrieved August 21, 2013, from http://www.ama-assn.org/resources/doc/washington/gme-funding-remains-in-critical-condition.pdf
Further Reading:
Iglehart JK. The residency mismatch. N Engl J Med. 2013;369(4):297-9.
Originally posted in the Columbia Tribune:
Nolan, N. S. (2013, August 25). Doc shortage has a remedy. Columbia Tribune. Retrieved August 25, 2013, from http://www.columbiatribune.com/opinion/oped/doc-shortage-has-a-remedy/article_71a1558c-0c56-11e3-8bee-10604b9f1ff4.html
